Ana Smolin

Maternal and neonatal outcome following cerebrovascular accidents during pregnancy

Objective. To assess the clinical characteristics of maternal and neonatal outcome among women with cerebrovascular accidents (CVA) during pregnancy. Methods. Our computerized database was used to identify patients with CVA during pregnancy and puerperium from January 1988 to March 2004. Their medical records were identified and reviewed. Results. There were 16 cases of CVA among 173 803 deliveries, giving a risk of almost one case per 10 000 pregnant women. Out of 16 patients, 14 (88%) had a stroke and the remaining two cases were diagnosed with venous thrombosis. Of those 14 cases, nine (64%) had ischemic strokes and five (36%) had hemorrhagic strokes. Ten of the CVAs occurred antepartum, two intrapartum and four postpartum. Hypertensive disorders were diagnosed in 75% (12/16) of the patients. Out of these 12 patients with hypertension, 9 (75%) suffered from preeclampsia. One woman had a history of chronic hypertension. Smoking was associated with 63% (10/16) of the cases. There were two maternal deaths, both in women who had hemorrhagic strokes, and both in the first half of the study (1994 and 1996). Nine out of 16 women (56%), were delivered within 48 hours of the CVA including 7 (78%) antepartum, and two (22%) intrapartum. Cesarean deliveries were performed in 11/16 women (69%) including 8/10 with CVAs occurring antepartum, 1/2 intrapartum and 2/4 postpartum. One case of neonatal mortality was identified in a patient who was delivered at 24 gestational weeks. Conclusions. (1) Hypertensive disorders and smoking were the most important factors associated with CVA during pregnancy. (2) Maternal mortality was high among patients with CVA during pregnancy. (3) Neonatal outcome was considered generally good in cases of CVA.

Evidence for abnormal middle cerebral artery values in patients with idiopathic hydramnios

Objective: Idiopathic hydramnios is an independent risk factor for perinatal morbidity and mortality, although the precise mechanism is unknown. Hydramnios may alter oxygen delivery to the human fetus. The middle cerebral artery (MCA) pulsatility index (PI) is a sensitive parameter for detection of blood flow redistribution or centralization. The aim of this study was to determine whether idiopathic hydramnios is associated with changes in the PI of the MCA and the umbilical artery (UA). Design: The PI of the MCA and UA were determined prospectively in 113 consecutive pregnant women with singleton pregnancies and idiopathic hydramnios (study group) and in 113 matched control patients with normal amniotic fluid (AF) volume (control group). The control group was matched for maternal age, gravidity, parity and gestational age at examination. Hydramnios was defined as an AF index above 24 cm. Patients with fetal structural or chromosomal anomalies and with diabetes mellitus were excluded. A PI below the 5th centile for the MCA was considered abnormal. Results: The rate of abnormal MCA PI was significantly higher in the study group than in the control group (30.9% (35/113) vs. 5.3% (6/113), respectively, OR 8.0; p < 0.0001; 95% CI 3.3-22.1). A significant inverse correlation was found between MCA PI and increasing AF index among patients with hydramnios ( p = 0.008, r = 0.46). In contrast, there were no significant differences between the UA PI (0.93 (0.57-2.06) vs. 1.0 (0.49-1.48), ( p = 0.20)) and MCA/UA (1.86 (0.77-2.01) vs. 2.15 (0.86-4.11), ( p = 0.14)) in both groups. Conclusions: Our observations provide evidence of cerebral blood flow redistribution in fetuses with idiopathic hydramnios.

Maternal rehospitalization after singleton term vaginal delivery.

Objective: To determine risk factors for maternal rehospitalization after term vaginal delivery. Study design: The study group consisted of all women who were rehospitalized following singleton vaginal deliveries during 1996-1998 (n = 194). The control group consisted of 427 women who were not rehospitalized during the same period. Results: The incidence of rehospitalization was 0.75% (194/25 885). Maternal chronic diseases, preterm contractions and pre-eclampsia rates were significantly higher among the study group as compared to the controls (25.3% vs. 8.4%, p < 0.001; 6.7% vs. 2.8%, p = 0.022; 9.3% vs. 4.9%, p = 0.037, respectively). Duration of labor was significantly longer in the study group as opposed to the controls (379 ± 406 min vs. 259 ± 276 min, p < 0.001). The rates of postpartum hemorrhage, blood transfusion and antibiotic treatment during delivery hospitalization were significantly higher among the study group (1.5% vs. 0.2%, p = 0.021; 4.6% vs. 0.7%, p < 0.001; 26.8% vs. 14.1%, p < 0.001, respectively). Using a forward logistic regression analysis, prolonged labor and blood transfusion during labor were found as independent risk factors associated with rehospitalization (OR 1.001, 95% CI 1.001-1.002, p = 0.001; OR 4.751, 95% CI 1.698-13.292, p = 0.003). In contrast, vertex presentation had a protective effect against rehospitalization (p = 0.027, OR 0.084, 95% CI 0.009-0.758). Conclusions: Blood transfusion and prolonged labor are independent risk factors for rehospitalization after term vaginal delivery. Special attention should be given during the early postpartum period to patients receiving blood transfusions and those with prolonged deliveries, in order to reduce rehospitalization rates.

Uterine Artery Doppler Velocimetry in Patients with Idiopathic Hydramnios

Objective: To evaluate the role of overdistended uterus on the uterine artery (UA) blood flow velocimetry by comparing UA Doppler in patients with idiopathic hydramnios to patients with normal amniotic fluid (AF) volume. Methods: Pulsatility index (PI) of both UAs was determined prospectively between 26 and 41 weeks of gestation in 72 consecutive pregnant women with singleton pregnancies and idiopathic hydramnios and in 72 pregnant women with normal AF volume. Hydramnios was defined as an AF index (AFI) above 24 cm. A normal amount of AF was defined as an AFI of 6–24 cm. Patients with known fetal structural or chromosomal anomalies and those with diabetes mellitus were excluded. Results: No significant differences were observed between the groups with regard to maternal age, gravidity, and gestational age at examination. Gestational age at delivery and accordingly birth weight were significantly lower in patients with hydramnios compared to those with a normal AFI (34.9 ± 2.1 vs. 39.1 ± 1.2, p < 0.001; 2,508 ± 399 vs. 2,995 ± 420, p < 0.001, respectively). No significant differences were noted between right UA PI (0.73 ± 0.3 in the hydramnios group vs. 0.71 ± 0.2 in the control group; p = 0.091) and left UA PI (0.91 ± 0.3 in the hydramnios group vs. 0.84 ± 0.3 in the control group; p = 0.131) of both groups. Conclusion: UA velocimetry in patients with idiopathic hydramnios was not significantly different from those with a normal AF volume.

Increased maternal serum human chorionic gonadotropin concentrations are an independent risk factor for SGA in dichorionic twin gestations

Objective. To determine maternal and neonatal complications among dichorionic and monochorionic twins with isolated midtrimester elevated maternal serum human chorionic gonadotropin (MShCG). Material and methods. MShCG was determined in 247 women with dichorionic twins and 32 women with monochorionic twins between 16–18 weeks gestation. Among the dichorionic twins 219 patients had MShCG < 2.5 MoM, 14 between 2.5–3.0 MoM and 14 above 3.0 MoM. Of the patients with monochorionic twins 15 had MShCG < 2.5MoM, nine between 2.5–3.0 MoM and 8 above 3.0 MoM. All patients had maternal serum α fetoprotein < 2.5 MoM. Karyotype was normal among all neonates. Statistical analysis was performed with SPSS package. Results. Patients with monochorionic twins had higher rates of cesarean section when MShCG was > 3.0 MoM (100% vs. 44%; p = 0.03) and of preterm delivery when MShCG was > 2.5 MoM (87.5% vs. 46.7%; p = 0.04). A non significant higher rate of small for gestational age (SGA) neonates was found when MShCG was > 2.5 MoM among first twin (37.5% vs. 13.3%; p = 0.08). In contrast, patients with dichorionic twins had higher rates of SGA neonates and low 1 minute Apgar scores in the second twin when MShCG was > 2.5 MoM (23.1% vs. 10%; p = 0.04, 15.4% vs. 11.9%; p < 0.01). A multivariate logistic regression model with forward stepwise selection was performed with SGA as outcome variable. The model included the following variables: MShCG, hypertensive disorders, gestational age at delivery, chorionicity, twin order, cesarean section (CS) and preterm delivery. MShCG levels were the only significant factor predicting SGA among bichorionic twins (OR 1.76, 95% CI 1.2–2.5). Conclusions. (1) Increased concentrations of MShCG are an independent risk factor for SGA among dichorionic twins. (2) MShCG > 2.5 MoM are associated with adverse maternal outcome among monochorionic twins.

OP11.10: Cervical length of ≤ 25 mm is an independent risk factor for preterm delivery among patients with vaginal bleeding at 22–34 weeks of gestation

Bangkok, Thailand between June 1999 and May 2003. The measurement of four-quadrant amniotic fluid index was performed by ultrasonography in the early intrapartum period. The amniotic fluid index < / = 5 cm was the cutoff point for the predicting of poor perinatal outcome. The result of amniotic fluid index was compared to the perinatal outcome using sensitivity, specificity, negative predictive value, positive predictive value and accuracy. Results: Among 450 high risk pregnancies, 92 cases (20.44%) were amniotic fluid index ≤ 5 cm, and 358 cases (79.56%) were amniotic fluid index > 5 cm. The incidence of poor perinatal outcome was 16.67%. An intrapartum amniotic fluid index of ≤ 5 cm, in comparison with > 5 cm, is associated with an increased risk of poor perinatal outcome (P < 0.05). The sensitivity, specificity, positive and negative predictive values and accuracy of four-quadrant amniotic fluid index ≤ 5 cm for predicting perinatal outcome were 72%, 89.86%, 58.69%, 94.13%, and 86.88%, respectively. Conclusion: An intrapartum amniotic fluid index of ≤ 5 cm is associated with a significantly increased risk of poor perinatal outcome. The amniotic fluid index measurement is an effective diagnostic test to identify fetus at risk in the intrapartum period of the high risk pregnancy.

P11.03: Vaginal bleeding and cervical length of ≤ 25 mm as predictors of preterm delivery. A prospective study

In the first case, microcephaly was diagnosed at 36 weeks’ gestation of a 27 years old healthy Caucasian. Intracranial calcifications were seen as well. In the second case fetal hydrops was diagnosed, with generalized edema and pericardial effusion, at 24th week gestation. The third case was concerned with hepatosplenomegally, diagnosed at 26th week gestation, with no other signs of fetal infection. In the last case, severe intra-uterine growth restriction, with signs of severe central nervous system occurred at 21st week gestation, with intrauterine fetal death followed at 24th week gestation. In all four cases, maternal serum was positive for anti-CMV IgG only, and negative for anti-CMV IgM. Amniotic fluid examinations were positive for CMV DNA detected by PCR, and also culture positive for CMV. Our conclusions from these cases were that amniotic fluid should be examined for CMV DNA and viral culture regardless of the maternal state of anti-CMV IgM, though this is generally concerned as the highlights for maternal recent seroconversion. Our concerns for severe fetal infection should not be mistakenly lowered because of a negative anti-CMV IgM test, and work-up should proceed with amniocentesis.

OC24.06: Short term effect of betamethasone administration on MCA blood flow velocimetry on preterm intrauterine growth restricted fetuses

Comment: In CHD fetuses, increased DV Index, associated with reduced forward ductal flow to the right atrium, well correlates with increased right atrial pressure occurring in right outflow tract obstruction or in hypoplastic left ventricle. On the contrary in IUGR fetuses with increased DV Index and compensatory ductal dilatation, normal left cardiac output suggests normal myocardial function due to a maintained or even increased forward flow through the DV to right atrium.

P05.19: Middle cerebral artery Doppler velocimetry in fetuses with intrauterine growth restriction: correlation with perinatal outcome and with neonatal brain sonography

Results: There are significant differences in PI values in normal pregnancy and pregnancy complicated by intrauterine growth restriction with hypoxia, especially in M2 segment. The prognostic values of abnormal M2 PI in prediction of fetal hypoxia were: sensitivity and positive predictive value of birthweight below 10 centile, 60 and 89%, respectively; sensitivity and negative predictive value of admission to NICU, 78 and 85%, respectively; and sensitivity and negative predictive value of artificial ventilation, 89 and93%, respectively. There were found low sensitivity and positive predictive value of pH and BE in umbilical artery, with high specificity and negative predictive value, 82 and 85%, 82 and 95%, respectively. Specificity and negative predictive value of pH and BE in umbilical vein, also were high, 85 and 89%, 84 and 100%, respectively. Conclusions: PI of M2 segments of the MCA seems to be a good predictor of fetal hypoxia during the second half of pregnancy complicated by growth restriction.